Why Improving Access to Health Care Does Not Save Money

One of the oft-repeated arguments in favor of the Affordable Care Act is that it will reduce people’s need for more intensive care by increasing their access to preventive care. For example, people will use the emergency room less often because they will be able to see primary care physicians. Or, they will not develop as many chronic illnesses because they will be properly screened and treated early on. And they will not require significant and invasive care down the line because they will be better managed ahead of time.

Moreover, it is often asserted that these developments will lead to reductions in health care spending. Unfortunately, a growing body of evidence makes the case that this may not be true.

One of the most important facts about health care overhaul, and one that is often overlooked, is that all changes to the health care system involve trade-offs among access, quality and cost. You can improve one of these – maybe two – but it will almost always result in some other aspect getting worse.

You can make the health care system achieve better outcomes. But that will usually cost more or require some change in access. You can make it cheaper, but access or quality may take a hit. And you can expand access, but that will increase cost or result in some change in quality.

The A.C.A. was primarily about access: making it easier for people to get insurance and the care it allows. The law also tries to make changes that may bend the curve of spending over time, but it’s important to acknowledge that of the three components of health care systems, access was the primary focus.

It is true that some people use the emergency room for minor problems. But that lack of access isn’t all about insurance. Even for the insured, one of the major reasons people use the emergency room is that it’s more convenient. That doesn’t change with the A.C.A.

Image

Tung Tran in the University of Miami Hospital's Emergency Department in 2012. One of the major reasons people, regardless of their insurance status, use the emergency room is that it’s more convenient. That doesn’t change with the Affordable Care Act.CreditJoe Raedle/Getty Images

It’s also important to remember that emergency room care is not free. It’s very expensive, and hospitals have been known to go after people aggressively to be paid. Going to the emergency room wasn’t a “better” option for those who were uninsured. It was the only option.

There were many people without insurance who would have benefited from care, but didn’t get it because they couldn’t afford it. It’s likely that, given Medicaid or very cheap private insurance, they would choose to obtain that care. There’s no reason they wouldn’t use the emergency room to get it, and that turns out to be what has happened in practice.

A study published in March examined how the health care overhaul in Massachusetts affected emergency department use there. Researchers found that increased insurance coverage resulted in more use of the emergency department, regardless of age and issue. Another study published on the Oregon Health Insurance Experiment found that giving people Medicaid also increased their use of the emergency department.

Even more recent studies show that increasing people’s access to care increases their use of more invasive care. Researchers in Michigan compared the prevalence of surgery in Massachusetts, New Jersey and New York both before and after Massachusetts went to universal insurance in 2007. They found that expanding coverage was associated with a more than 9 percent increase in discretionary operations and a 4.5 percent increase in nondiscretionary ones. They estimated, based on their results, that the A.C.A. could lead to more than 465,000 additional discretionary surgical procedures within a few years from now.

Finally, it is a common misconception that prevention always saves money. It is true that there are certain interventions that are cost-saving, such as childhood immunizations and newborn screening. But these are relatively rare. A review of preventive measures in the New England Journal of Medicine found that less than 20 percent of 279 preventive measures saved money. The rest resulted in varying amounts of increased spending.

It’s important to note that this isn’t necessarily a bad thing. Sometimes good things cost money. It’s likely that many of the people who went to the emergency room or got those surgical procedures needed that care. It’s likely that much of it will improve their health long term. And many, many preventive measures are cost-effective in the sense that the improvements in health are worth the added spending.

More people being able to get care was the point of the A.C.A. It’s possible that overall health care spending may remain flat or even decrease because of other changes to the health care system, or economic factors outside the system entirely. But with respect to emergency care, prevention and procedures, we should expect that increasing access will lead to more spending, not less.

It’s understandable that supporters of the law want it to increase access, increase quality and decrease spending all at the same time, but that’s very unlikely. Tradeoffs occur; we need to be honest, and prepared, for what’s likely to happen.